Nursing Elites

1. The nurse is preparing to give a dose of a cephalosporin medication to a patient who has been receiving the antibiotic for 2 weeks. The nurse notes ulcers on the patient’s tongue and buccal mucosa. Which action will the nurse take?

• A. Hold the drug and notify the provider.
• B. Obtain an order to culture the oral lesions.
• C. Gather emergency equipment to prepare for anaphylaxis.
• D. Report a possible superinfection side effect of the cephalosporin.

Correct answer: D

Rationale: The nurse should report a possible superinfection side effect of the cephalosporin to the physician as the patient's symptoms may indicate a superinfection that requires treatment. Holding the drug is not necessary unless directed by the provider. Culturing the lesions is not indicated for this situation. There is no evidence to suggest impending anaphylaxis based on the patient's symptoms.

2. What is the most common cause of urinary tract infections (UTIs)?

• A. Escherichia coli infection
• B. Staphylococcus aureus infection
• C. Pseudomonas aeruginosa infection
• D. Klebsiella pneumoniae infection

Correct answer: A

Rationale: Escherichia coli is the most common cause of urinary tract infections (UTIs). It is responsible for the majority of UTIs, especially in women. E. coli is a normal inhabitant of the bowel and can enter the urinary tract through the urethra, leading to infection. Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae are less common causes of UTIs compared to E. coli. Staphylococcus aureus typically causes skin and soft tissue infections, Pseudomonas aeruginosa is more commonly associated with healthcare-associated infections, and Klebsiella pneumoniae is known for causing pneumonia and other respiratory infections.

3. A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than:

• A. 7%
• B. 9%
• C. 10%
• D. 15%

Correct answer: A

Rationale: The correct answer is A: 7%. Glycosylated hemoglobin A1C (HbA1C) level of 7.0% or less is considered indicative of adequate diabetic control. This level reflects good long-term blood sugar management. Choices B, C, and D are incorrect because an HbA1C level above 7% indicates poor diabetic control and an increased risk of complications associated with diabetes, such as cardiovascular disease, neuropathy, and retinopathy.

4. A client has made an appointment for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should tell the client that:

• A. The test cannot be performed while the client is menstruating
• B. Vaginal douching is required at least 24 hours before the test
• C. Spicy foods should not be eaten on the day of the test
• D. The test has absolutely no discomfort associated with it

Correct answer: A

Rationale: The correct answer is A. A Pap smear cannot be performed with accurate results during menstruation. Menstrual blood may interfere with the test results. Choice B is incorrect as vaginal douching should be avoided for at least 24 hours before the test to prevent altering the cervical cells. Choice C is incorrect as there is no restriction on spicy foods before a Pap smear. Choice D is incorrect as some women may experience mild discomfort during the test, although it is generally well-tolerated.

5. A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?

• A. Placing the tube in warm water
• B. Hyperextending the head while inserting the tube
• C. Removing the tube if any resistance to insertion is met
• D. Asking the client to swallow as the tube is being advanced

Correct answer: D

Rationale: The correct action for the nurse to take to insert a nasogastric tube safely and easily is asking the client to swallow as the tube is being advanced. This action helps facilitate the passage of the tube through the esophagus into the stomach. Placing the tube in warm water (Choice A) is not a recommended practice for nasogastric tube insertion. Hyperextending the head (Choice B) can cause discomfort and is not necessary for safe insertion. Removing the tube if resistance is met (Choice C) is incorrect as it may cause harm or discomfort to the client. Asking the client to swallow helps the tube pass more smoothly and comfortably.

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